Data: pt states has been drinking regularly and reason for wife leaving

Pt states drinking heavily in past few days (a gallon of vodka on day of
admission)

Pt states used marijuana 5 days prior

7. Situational Low Self-Esteem related to loss and current living situation as
evidenced by patient stating doesn’t feel good about himself, doesn’t want to
“look like this”, and expressing feelings of helplessness.

Data: pt states doesn’t want to not be able to shower, get hair cut or shave

Pt states doesn’t want to feel like this or be sick

Pt states wants to work and get life together

Pt feels as if no where to start because has been left with nothing and doesn’t
feel he has resources

8. Loneliness related to social isolation and affectional deprivation as
evidenced by marital problems, homelessness, and lack of family and social
support.

Data: pt states wife left with children and marriage has ended

Pt states no other family to rely on for help

Pt states friends aren’t “real friends”

Pt states occasionally staying in friends basement but can only go late at night
when friend’s wife is asleep b/c she doesn’t like him

5. Communication of concerns in a supportive environment can facilitate the development
of adaptive coping behaviors.
Continues the development of a trusting relationship (Newfield, Hinz,
Tilley, Sridaromont, &Maramba, 2007).

1. BG stated his father was an alcoholic.He stated he hasn’t always drank but
stress and feeling depressed triggers his drinking.

2. BG identifies that his marital problems, wife
seeing a coworker of his, and separation from his kids are situations that cause
him great stress.Being homeless and
unemployed are also key factors that contribute to his alcohol use.

3. BG stated he uses alcohol just as something to
do.He stated if he had somewhere to
live and shower, he would feel good about himself and wouldn’t need to drink.He also states because he is unkept
he can’t find work.

4. BG is well aware how alcohol is affecting him.He is very clear about not wanting to
use alcohol as his support system but feels he has no one else to turn to and no
outlet.BG stated he was going to
try to make contact with his old boss and see about working again once he is
discharged.

5. BG warmed up very quickly and shared his
concerns about the future.He also
described his marital situation and how it has affected him.He said he hadn’t talked to any
professionals during his stay other than a social worker for 5 minutes.He said she gave him a halfway house
and told him the cost involved.He
stated he didn’t feel he had received help. He did seem happy that he had
someone to talk to.He smiled often
during the conversation but didn’t laugh.

6. Patient states was given half way house contact
and has looked into homeless shelters.Patient aware of AA services.
Patient states drinking became out of control when wife left, and he was left
homeless.BG states drinks out of
boredom and loneliness.

7. BG expressed that hadn’t been referred or
helped with resources other than half way house.I spoke with clinical instructor and she provided some helpful ideas and
suggestions and stated she would share with BG the following week before
discharge.

Summarize
impressions of client progress toward outcomes / problem resolution: More time is needed to evaluate interventions and
to determine if goals are met and with BG being discharged 3-5 days after
admission, I’m not sure it’s possible for him to complete these tasks.BG will need a social worker or case
manager in order to manage his care and evaluate and adjust interventions and
goals.BG was able to discuss his
history of alcohol abuse, identify situations causing him stress and making him
feel as if he needs to use alcohol, and identify negative effects of alcohol
abuse.BG does have a hard time
coming up with solutions and alternatives to drinking, primarily because he
feels as if he has no way out because he is unemployed and homeless at this
time.BG stated several times if he
“had a place to go, he wouldn’t be doing this”, this being drinking.BG did open up when I sat and had a
discussion with him and stated he hadn’t spoke to a professional for more than 5
minutes since he’d been there (3 days).He did express that he felt resources were limited in terms of the
resources he could utilize.I think
a case manager or social worker who could work with him and help him come up
with a plan that is productive and he can comply with would be beneficial.BG
expressed he wants to not use drinking as his outlet but his concern of not
having a place to live and shower is overwhelming.He stated his appearance was
important to him and not being able to shower, shave, and get a haircut is
preventing him from applying himself.He stated he didn’t want his kids to “see him like this”, referring to
being unshaven and not having showered.BG stated is welcome to suggestions and will utilize resources if
available.